Why Was My Health Insurance Claim Denied? Common Reasons

Every service on a bill has a code. A wrong code, a diagnosis that does not match the service, or a typo in your name, date of birth, or member ID number can cause a denial even when the care is covered.

First fix: call the provider's billing office. Ask them to check the codes and your insurance information against your card and to send a corrected claim. Ask when they will resubmit it, and call back to confirm.

An insurer may deny a claim because it looks like one it already received for the same service, for example if the provider sent it again while the first was still being processed.

First fix: look through your EOBs for an earlier claim with the same date of service. If the first claim was paid or is still in process, the duplicate denial may not be a problem. Ask the billing office to confirm which claim is the active one.

Coordination of benefits is the way plans figure out who pays first when two or more plans could pay the same claim. This can come up if you are covered by your own employer-sponsored plan and a spouse's plan, or if a child is covered under two parents' plans.

A claim can be denied or held if the insurer does not know about your other coverage, or if the wrong plan was billed first. First fix: tell your insurer about all of your coverage, ask which plan is primary, and give the billing office that information.

Many health plans set a time limit for filing a claim, such as within 90 days of the service. A claim filed after the plan's limit can be denied for that reason alone.

First fix: ask the billing office to show you the date the claim was first submitted. If it was sent on time, they can resubmit it with proof. If you are filing the claim yourself, file as soon as you can and check your plan documents for the limit.

Prior authorization is approval from your plan that may be required before you get certain care. If it was required and not obtained, the claim can be denied.

First fix: ask your doctor's office whether approval was requested, and when. They may be able to send the request or supporting information now. Our separate article on denied prior authorizations covers this in detail.

A network is the group of doctors, hospitals, and other providers your plan has contracted with. Depending on your plan, care outside the network may be paid at a lower level or not at all.

First fix: confirm whether the provider was in your network on the date of service, and whether your plan covers out-of-network care at all. For most types of health insurance, federal rules protect you from some surprise out-of-network bills for emergency care and for certain care at in-network facilities, so ask whether that applies.

Every plan excludes some services. The denial notice should name the plan provision it relied on, so read that section of your plan documents.

First fix: confirm the service was billed with the right code, because a billing mistake can make a covered service look excluded. If the plan truly excludes it, an appeal may not change that. Ask your provider about other options.

Medically necessary care is care needed to diagnose or treat an illness, injury, or condition and that meets accepted standards of medicine. When an insurer says a service was not medically necessary, it is making a medical judgment about your case.

First fix: for a denial based on medical reasons, ask your doctor to contact the plan and request reconsideration with additional information, such as a letter and records. For job-based plans, the notice must explain the clinical reasoning or say it is available free on request, so ask for it.

A claim can be denied if the plan shows that your coverage had not started, or had ended, on the date of service. This can happen after a missed payment, a job change, or a paperwork delay.

First fix: call the insurer and ask what coverage dates it has on file. If they look wrong, ask who needs to correct them, such as your employer or the insurer, and ask the provider to resubmit afterward.